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'' MEDITECH INSTRUCTIONS: 1. Click “Enter New” (on the right-hand navigation menu) 2. Search “Student History & Physical,” add to favorites 3. Click “Add Section” (on the right-hand navigation menu)  search “History & Physical – blank,” add to favorites 4. Copy & paste the template below into the “H&P-BLANK” section of your note 5. Press F2 on the keyboard to tab through all the parts of the history that need to be changed for your individual patient 6. Click “Quick Save” '' ---- CHIEF COMPLAINT: [] HPI: [] yo G[]P[] at [] []/7 WGA by last menstrual period consistent with [] week ultrasound who presents to labor and delivery triage with []. HPI... Patient denies []vaginal bleeding, []loss of fluids, []contractions. []Reports active fetus. Prenatal care uncomplicated diabetes, hypertension. Patient has been receiving prenatal care atwith Dr. []. Estimated due date []. Last menstrual period []. OB HISTORY: G1 year NSVDCD at [] weeks, []no complicationspreterm, hypertension, preeclampsia, malefemale, weight G2 year NSVDCD at [] weeks, []no complicationspreterm, hypertension, preeclampsia, malefemale, weight G3 year NSVDCD at [] weeks, []no complicationspreterm, hypertension, preeclampsia, malefemale, weight G4 year NSVDCD at [] weeks, []no complicationspreterm, hypertension, preeclampsia, malefemale, weight GYN HISTORY: Menses: Menarche at 13, []regular every month, lasts 4-5 days STDs: patient reports no history of STIs, []consistent with chart review Abnormal Paps: no documented abnormal pap smears, patient denies PMH: [] PSH: [] FAMILY HISTORY: []no family history of birth defects or genetic disorders SOCIAL HISTORY: []denies tobacco, alcohol, drugs MEDICATIONS: []prenatal vitamins ALLERGIES: NKDA (anaphylaxis) ROS: [] all systems reviewed and negative except as noted in HPI. PHYSICAL EXAM: “VITAL SIGNS - LAST 24 HR RANGE” AND “VITAL SIGNS - FIRST DOCUMENTED” HERE - click “Data Formats” on right-hand menu & search for these) Gen: []alert and awake HEENT: []normocephalic, no periorbital edema CV: []regular rate, warm and well perfused Resp: []aerating well, no respiratory distressclear to auscultation bilaterally Abd: []soft, gravid, fundal height appropriate Extremities: []no clubbing, no cyanosis, []trace edema on lower extremities Pelvic: []adequate pelvis, EFW[] Cervix: []/[]/[] Skin: Supple, intact, no rashes Neuro: alert and oriented x3, CN II-XII grossly intact MEDICAL DECISION MAKING: Prenatal Labs: Blood Type [] Rubella immune RPR non-reactive HIV negative HBV negative Gonorrhea negative Chlamydia negative 1-hour GTT [] Pap normal GBS [] External Fetal Heart Rate Monitor: [] baseline HR with moderate variability, []accelerations present, []no decelerations Tocometry: [] contractions Bedside U/S: [] [ (ENTER “ALL LAB/MICRO/RAD LAST 16 HRS” AND “CBC-FISHBONE ONLY” HERE – click “Data Formats” on right-hand menu & search for these) ] ASSESSMENT: [] yo G[]P[] at [] []/7 WGA by LMP c/w [] week ultrasound here for []. 2) labor 3) fetal status 4) presentation 5) GBS[] PLAN: 1. Admit to Labor & Delivery. (If patient is less than 39 wga, the indication for delivery is [] and the patient was counseled on the slightly increased risk of fetal morbidity/mortality at this gestational age, however, the benefits of delivery prior to 39 weeks outweigh the risks at this time.) 2. Consent obtained 3. Admit labs drawn 4. Fetal heart rate and contraction monitoring 5. Start Pitocin as clinically indicated 6. Consult anesthesia for epidural as requested by patient 7. Labor & delivery course discussed with patient; questions answered 8. Patient care plan discussed with attending physician Dr. []